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Carisoprodol Withdrawal Syndrome


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Presentation done by Pallav Pareek M.D. indicating the withdrawal phenomenon seen with the use of carisoprodol. Presented at Sinai Grace Research day May 2011.

Published in: Education, Health & Medicine
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Carisoprodol Withdrawal Syndrome

  1. 1. Carisoprodol withdrawal syndrome <ul><li>Pallav Pareek M.D. </li></ul><ul><li>Acknowledgements </li></ul><ul><li>Gerald. A. Shiener M.D. </li></ul><ul><li>Leonard L. Lachover M.D. </li></ul><ul><li>RP Rajarethinam M.D. </li></ul>
  2. 2. What on earth is Carisoprodol? <ul><li>a.k.a SOMA, available as 250 and 350 mg white round tablets. </li></ul><ul><li>1959: Pharmacologists convened @ Wayne State University </li></ul><ul><li>N -isopropyl-2 methyl-2-propyl-1,3-propanediol dicarbamate </li></ul><ul><li>MOA not known, believed to act through GABA A receptor </li></ul><ul><li>Carisoprodol also has weak anticholinergic and antipyretic properties </li></ul><ul><li>Half life: 2-3 hrs </li></ul><ul><li>Used -> primary care settings for musculoskeletal pain relief esp. lower back </li></ul>
  3. 4. Why Worry? <ul><li>Easily available, and is not controlled in most US states. </li></ul><ul><li>An active metabolite meprobamate: schedule IV controlled substance in U.S. </li></ul><ul><li>Mebrobamate risk of addiction potential equal (if not greater) to benzo’s </li></ul><ul><li>Carisprodol is not a controlled substance at federal level and in MI </li></ul><ul><li>DAWN: Soma -> ER visits ↑300% (94-05) </li></ul>
  4. 5. Case Report <ul><li>Identifying data: SS is a 55 yo AASF, lives with boyfriend, never married, no children, unemployed, SSD(705$/mo) </li></ul><ul><li>Chief complaint: Per patient “I don’t know why Iam here” psychiatry consulted for “dystonic reactions” </li></ul><ul><li>Day 1: Presented to ER with rhythmic jerky abnormal movements in both U&LE, presumed by ER as manifestation of a psychiatric illness. </li></ul><ul><li>Complete neurological work-up including a CT scan performed. No focal deficits found. Seizures ruled out. </li></ul>
  5. 6. <ul><li>Did not have any manifestation of any psychiatric illness -> cleared by psychiatry </li></ul><ul><li>No neurological or medical etiology of her manifestation was found -> Patient d/c home </li></ul><ul><li>Day 2: Patient again presented to the ER with similar presentation, this time with altered mental state, anxiety, tremulousness, muscle twitching, unsteady gait and abnormal movements in U&LE </li></ul>
  6. 7. <ul><li>Past Psychiatric Hx: Hx of Bipolar disorder vs. schizoaffective disorder. 4-5 previous inpatient admissions. Current O/P Psych Rx: Risperdal 4 mg QHS </li></ul><ul><li>Substance abuse: </li></ul><ul><li>- Smoking: quit 2 yrs ago. </li></ul><ul><li>- Alcohol : abstinent for last 2 years </li></ul><ul><li>- Marijuana : 50 $/week </li></ul><ul><li>- Tylenol #3: as much as she can get a hold of from Physicians or from street. </li></ul><ul><li>- Soma: Gets 60-90 pills from a PCP, sinusoidal pattern of use. </li></ul>
  7. 8. <ul><li>Medical Hx: osteoporosis, arthritis, chronic low back pain, s/p polypectomy. No active ongoing medical problems. </li></ul><ul><li>Family Hx: non-contributory </li></ul><ul><li>Mental Status: 55 yo f, appeared ↑ stated age. Fair grooming and hygiene, mild tremors in b/l UE, speech soft, ↑ latency, mood euthymic, affect constricted, -A/VH, thought process linear and goal directed, intact remote memory, no memory for recent events including her being in hospital, fair calculation, abstraction & reasoning </li></ul>
  8. 9. Labs <ul><li>Most: WNL </li></ul><ul><li>CPK :1890 </li></ul><ul><li>UDS: + for cannabinoids and opioids </li></ul><ul><li>Urinalysis: 1+ blood </li></ul><ul><li>EKG: Sinus tachycardia </li></ul><ul><li>EEG: No epileptiform activity or focal features seen </li></ul>
  9. 10. Management <ul><li>Neurology, Psychiatry, Toxicology were consulted </li></ul><ul><li>Maintained on minimal possible medications. </li></ul><ul><li>Symptomatically managed </li></ul><ul><li>Day 4 : Patient returned to baseline, no active symptoms, no recollection of the episode. D/C home </li></ul>
  10. 11. Why is Soma abused? <ul><li>Clinical effect/abuse: from carisoprodol v/s metabolite meprobamate not known </li></ul><ul><li>Per se : sedative and relaxant effect </li></ul><ul><li>Augments other drugs e.g. : ↑ sedative effect of alcohol or benzos </li></ul><ul><li>Alter other drugs: prevent jitteriness due to cocaine (or other stimulant) use </li></ul><ul><li>Combination : carisoprodol + tramadol: significant relaxation and euphoria </li></ul>
  11. 12. Reeves RR 2009:Pattern of use <ul><li>Study of 40 pts, with use > 3mo </li></ul><ul><li>N=20 (other drugs) </li></ul><ul><li>40% use ↑ prescribed </li></ul><ul><li>30% other than the effects for which prescribed </li></ul><ul><li>10% : for augmentation </li></ul><ul><li>5%: to counter other drugs </li></ul>
  12. 13. Physician awareness <ul><li>2009 study N=100 </li></ul><ul><li>95% aware: meprobamate is controlled vs. 39% felt: carisoprodol has abuse potential vs. 18% aware: C ->M </li></ul><ul><li>PDR: no wdrwl in dogs 1g/kg/d </li></ul><ul><li>Kentucky: physician guidelines “should be prescribed with same caution as opioid and other controlled subs..” </li></ul><ul><li>DEA: hearing pending 3/26/10 </li></ul>
  13. 14. More Worries, including www… <ul><li>Is still a scheduled drug in just 14 states </li></ul><ul><li>Physicians often choose this as a less harmful/addictive option </li></ul><ul><li>Internet is a boon… </li></ul><ul><li>Attractive and unmonitored means of procuring carisoprodol </li></ul>
  14. 15. Conclusions <ul><li>Several case reports suggest withdrawal potential of soma </li></ul><ul><li>Important but under recognized syndrome </li></ul><ul><li>Appropriate caution in cases with hx drug abuse </li></ul><ul><li>Cautious : if needed chroninc/long term </li></ul><ul><li>Can often masquerade as a psychiatric or neurological illness </li></ul><ul><li>Is it time to make it a controlled substance at federal level? </li></ul>
  15. 16. Conclusions….contd <ul><li>Slow taper over 2-4 wks is recommended </li></ul><ul><li>Withdrawal: No standard protocol </li></ul><ul><li>Carisoprodol levels (through DMC lab) </li></ul><ul><li>Benzodiazepines may be used for anxiety, myoclonus, ataxia and seizures </li></ul><ul><li>Flumazenil has been used to counter the intoxications of carisoprodol </li></ul><ul><li>Consensus on symptomatic management </li></ul>
  16. 17. Thank You!!! <ul><li>“ If it's your job to eat a frog, it's best to do it first thing in the morning. And If it's your job to eat two frogs, it's best to eat the biggest one first.” Mark Twain </li></ul>